Prescribed Drugs Provider Manual - Iowa Department of Human ...

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage21DateAugust 1, 20131. Completing a Prior Authorization RequestEach category of prior authorization uses a specific request form to reflect thecriteria for approval. The following instructions refer to items common to allRequests for Prior Authorization.IA MEDICAID MEMBER ID #: Copy this number directly from the member’sMedical Assistance Eligibility Card. This number must be eight positions inlength (seven numeric digits and one alphabetical character).PATIENT NAME: Provide the first and last name of the member. Use theMedical Assistance Eligibility Card for verification.DATE OF BIRTH (DOB): Copy the member’s date of birth directly from theMedical Assistance Eligibility Card. Use two digits for each: month, day, year(i.e., 04/11/67).PATIENT ADDRESS: Enter the member’s home address.PRESCRIBER NUMBER: Enter the national provider identifier (NPI) of theprescribing practitioner.PRESCRIBER NAME: Enter the name of the prescribing practitioner.PRESCRIBER PHONE NUMBEr: Enter the prescriber’s office phone number.PRESCRIBER ADDRESS: Enter the prescriber’s office address.PRESCRIBER FAX NUMBER: Enter the prescribing practitioner’s office FAXnumber.PHARMACY NAME: Enter the name of the pharmacy where the prescriptionwill be filled.PHARMACY ADDRESS: Enter the street address and city of the pharmacy.PHARMACY PHONE NUMBER: Enter the phone number of the pharmacy.PHARMACY NPI: Enter the pharmacy national provider identifier (NPI)number.